Temporal bone dysplasia in Coffin-Siris syndrome.

We report a child, diagnosed with Coffin-Siris syndrome (CSS), with chronic right otorrhoea. CT and DR-MRI were performed to further investigate, diagnose and determine relevant surgical anatomy. CT temporal bones assessment was performed, and the measurements compared with previously published data for normal temporal bone anatomy. These comparisons highlighted various differences which were not initially expected; it showed that there were multiple inner ear abnormalities in addition to middle ear disease. This case highlights the importance of considering temporal bone abnormalities in all children with CSS or any dysmorphia, when they may require mastoid procedures. Reviewing the management of this case provides relevant learning opportunities for both primary, secondary and tertiary care institutions.

Computed tomographic imaging of meningiomas.

Although magnetic resonance imaging (MRI) has surpassed computerized tomography (CT) as the imaging modality of choice, there are certain instances when CT should be a preoperative requisite for meningioma surgical resection. Given its superior bone definition and the propensity for meningiomas to invade bone (as evidenced by hyperostosis on imaging), CT can be extremely helpful to the surgeon when planning and evaluating postoperatively the extent of bone removal during tumor resection. Advances in CT imaging also allow for visualization of the adjacent arterial and venous vasculature to determine feasibility of resection and likelihood of adjuvant treatments such as radiosurgery to a tumor residuum. For skull base tumors high-resolution CT imaging as part of the standard neuronavigation sequences can help evaluate bony anatomy and planning of surgical approaches, in particular for cranial base tumors. Finally, 3D-CT imaging is important in the design of cranial prostheses, which may be required to repair defects as a result of resection.

Protocol for a randomised, single-blind, two-arm, parallel-group controlled trial of the efficacy of rhinothermy delivered by nasal high flow therapy in the treatment of the common cold.

INTRODUCTION: The common cold is the most common infectious disease affecting humans. It is usually a self-limiting disease; however, the common cold can cause significant morbidity and has a substantial economic impact on society. Human rhinoviruses (HRVs), which cause up to two-thirds of colds, have temperature-dependent replication and most HRV strains replicate optimally at 33°C. Delivery of heated, humidified air to the upper airways has the potential to reduce viral replication, but evidence of the effectiveness of this treatment of the common cold is inconclusive. We plan to test the hypothesis that delivery of humidified air heated to 41°C at high flow, nasal high flow rhinothermy (rNHF), for 2 hours daily for five days is more effective in reducing common cold symptom severity and duration than five days of 'sham' rhinothermy. METHODS AND ANALYSIS: This is a randomised, single-blind, parallel-group trial comparing rNHF to 'sham' rhinothermy in the treatment of common cold. We plan to recruit 170 participants within 48 hours of the onset of symptoms of common cold and randomise them 1:1 to receive one of the two treatments for five days. The study duration is 14 days, which includes clinic visits on the first day of randomisation and four days post-randomisation, and a phone call on the 14th day. Participants will complete daily symptom diaries which include a symptom score, the Modified Jackson Score (MJS). The primary outcome is the MJS after four days. ETHICS AND DISSEMINATION: New Zealand Ethics Registration: 17/STH/174. Results will be published in a peer-reviewed medical journal, presented at academic meetings, and reported to participants. TRIAL REGISTRATION NUMBER: U1111-1194-4345 and ACTRN12617001340325; Pre-results.

Nasal high-flow therapy compared with non-invasive ventilation in COPD patients with chronic respiratory failure: A randomized controlled cross-over trial.

BACKGROUND AND OBJECTIVE: Non-invasive ventilation (NIV) is part of the standard of care for hypercapnic respiratory failure secondary to COPD, but may be poorly tolerated. Preliminary evidence suggests nasal high-flow (NHF) therapy may improve hypercapnia in COPD and be well tolerated. We compared NHF and NIV in people with COPD and chronic hypercapnic respiratory failure. METHODS: Single-blind randomized controlled two-way cross-over single-centre trial was conducted in New Zealand. Twenty-four participants with stable hypercapnic COPD received: NHF at 45 L/min and NIV at 15/4 cm H2 O, each for 60 min with a 15-min washout in between. The primary outcome was transcutaneous partial pressure of carbon dioxide (PtCO2 ) at 60 min, adjusted for baseline. RESULTS: NIV reduced the PtCO2 more than NHF (mean (SD) at 60 min by -5.3 (5.0) vs -2.5 (3.5) mm Hg; difference: -2.8 (-5.0 to -0.5) P = 0.021). Difference across all time points was -2.5 mm Hg (95% CI -4.5 to -0.5, P = 0.016). There was no significant difference in the proportion of participants with a reduction of PtCO2 ≥ 4 or ≥ 8 mm Hg. Participants rated NHF significantly better for ease of application, comfort and fit. CONCLUSION: In stable COPD patients with chronic hypercapnia, NIV resulted in a greater reduction in PtCO2 compared with NHF, which was of uncertain clinical significance. NHF was better tolerated than NIV and may be a therapeutic option for some people with hypercapnic respiratory failure. CLINICAL TRIAL REGISTRATION: ACTRN12616001701415 at www.anzctr.org.au.

Oxygen versus air-driven nebulisers for exacerbations of chronic obstructive pulmonary disease: a randomised controlled trial.

BACKGROUND: In exacerbations of chronic obstructive pulmonary disease, administration of high concentrations of oxygen may cause hypercapnia and increase mortality compared with oxygen titrated, if required, to achieve an oxygen saturation of 88-92%. Optimally titrated oxygen regimens require two components: titrated supplemental oxygen to achieve the target oxygen saturation and, if required, bronchodilators delivered by air-driven nebulisation. The effect of repeated air vs oxygen-driven bronchodilator nebulisation in acute exacerbations of chronic obstructive pulmonary disease is unknown. We aimed to compare the effects of air versus oxygen-driven bronchodilator nebulisation on arterial carbon dioxide tension in exacerbations of chronic obstructive pulmonary disease. METHODS: A parallel group double-blind randomised controlled trial in 90 hospital in-patients with an acute exacerbation of COPD. Participants were randomised to receive two 2.5 mg salbutamol nebulisers, both driven by air or oxygen at 8 L/min, each delivered over 15 min with a 5 min interval in-between. The primary outcome measure was the transcutaneous partial pressure of carbon dioxide at the end of the second nebulisation (35 min). The primary analysis used a mixed linear model with fixed effects of the baseline PtCO2, time, the randomised intervention, and a time by intervention interaction term; to estimate the difference between randomised treatments at 35 min. Analysis was by intention-to-treat. RESULTS: Oxygen-driven nebulisation was terminated in one participant after 27 min when the PtCO2 rose by > 10 mmHg, a predefined safety criterion. The mean (standard deviation) change in PtCO2 at 35 min was 3.4 (1.9) mmHg and 0.1 (1.4) mmHg in the oxygen and air groups respectively, difference (95% confidence interval) 3.3 mmHg (2.7 to 3.9), p < 0.001. The proportion of patients with a PtCO2 change ≥4 mmHg during the intervention was 18/45 (40%) and 0/44 (0%) for oxygen and air groups respectively. CONCLUSIONS: Oxygen-driven nebulisation leads to an increase in PtCO2 in exacerbations of COPD. We propose that air-driven bronchodilator nebulisation is preferable to oxygen-driven nebulisation in exacerbations of COPD. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry number ACTRN12615000389505 . Registration confirmed on 28/4/15.

Randomised controlled trial of rhinothermy for treatment of the common cold: a feasibility study.

OBJECTIVE: To determine the feasibility of a randomised controlled trial (RCT) of rhinothermy for the common cold. DESIGN: Open label, randomised, controlled feasibility study. SETTING: Single-centre research institute in New Zealand recruiting participants from the community. PARTICIPANTS: 30 adult participants with symptoms of a common cold, presenting within 48 hours of the onset of symptoms. INTERVENTIONS: Participants were randomly assigned 2:1 to receive either 35 L/min of 100% humidified air at 41°C via high flow nasal cannulae, 2 hours per day for up to 5 days (rhinothermy), or vitamin C 250 mg daily for 5 days (control). PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was the proportion of screened candidates who were randomised. Secondary outcomes included: proportion of randomised participants who completed the study; modified Jackson scores from randomisation to 10 days after initiation of randomised regimen; time until feeling 'a lot better' compared with study entry; time until resolution of symptoms or symptom score at 10 days postrandomisation; proportion of organisms identified by PCR analysis of nasal swabs taken at baseline; the patterns of use of the rhinothermy device; estimated adherence of the control group; and rhinothermy device tolerability. RESULTS: In all 30/79 (38%, 95% CI 27% to 50%) of potential participants screened for eligibility were randomised. Rhinothermy was well tolerated, and all randomised participants completed the study (100%, 95% CI 88% to 100%). The reduction from baseline in the modified Jackson score was greater with rhinothermy compared with control at days 2, 3, 4, 5 and 6, with the maximum difference at day 4 (-6.4, 95% CI -9.4 to -3.3). The substantial clinical benefit threshold for modified Jackson score was a 5-unit change. CONCLUSIONS: This study shows that an RCT of rhinothermy compared with low-dose vitamin C in the treatment of the common cold is feasible. TRIAL REGISTRATION NUMBER: ACTRN12616000470493; Results.

Nasal high flow therapy and PtCO2 in stable COPD: A randomized controlled cross-over trial.

BACKGROUND AND OBJECTIVE: Hypercapnia is associated with worse clinical outcomes in exacerbations of COPD. The present study aimed to determine the effects of nasal high flow (NHF) therapy on transcutaneous partial pressure of carbon dioxide (PtCO2 ) in stable COPD patients. METHODS: In a single-blind randomized controlled cross-over trial, 48 participants with COPD were allocated in random order to all of four 20 min interventions: NHF at 15 L/min, 30 L/min and 45 L/min or breathing room air with each intervention followed by a washout period of 15 min. The primary outcome measure was PtCO2 at 20 min, adjusted for baseline PtCO2 . Secondary outcomes included respiratory rate at 20 min, adjusted for baseline. RESULTS: The mean (95% CI) change in PtCO2 at 20 min was -0.6 mm Hg (-1.1 to 0.0), P = 0.06; -1.3 mm Hg (-1.9 to 0.8), P < 0.001; and -2.4 mm Hg (-2.9 to -1.8), P < 0.001; for NHF at 15 L/min, 30 L/min and 45 L/min compared with room air, respectively. The mean (95% CI) change in respiratory rate at 20 min was -1.5 (-2.7 to -0.3), P = 0.02; -4.1 (-5.3 to -2.9), P < 0.001; and -4.3 (-5.5 to -3.1), P < 0.001; breaths per minute compared with room air, respectively. CONCLUSION: NHF results in a small flow-dependent reduction in PtCO2 and respiratory rate in patients with stable COPD.

High flow or titrated oxygen for obese medical inpatients: a randomised crossover trial.

OBJECTIVE: To compare the effects on transcutaneous carbon dioxide tension (Ptco2) of high concentration and titrated oxygen therapy in medical inpatients with morbid obesity who were not selected for a pre-existing diagnosis of obesity hypoventilation syndrome. DESIGN: A randomised, crossover trial undertaken between February and September 2015. SETTING: Internal medicine service, Wellington Regional Hospital, New Zealand. PARTICIPANTS: 22 adult inpatients, aged 16 years or more, with a body mass index exceeding 40 kg/m2. INTERVENTIONS: Participants received in random order two 60-minute interventions, with a minimum 30-minute washout period between treatments: titrated oxygen therapy (oxygen delivered, if required, via nasal prongs to achieve peripheral oxygen saturation [Spo2] of 88-92%), and high concentration oxygen therapy (delivered via Hudson mask at 8 L/min, without regard to Spo2). Ptco2 and Spo2 were recorded at 10-minute intervals. MAIN OUTCOME MEASURE: Ptco2 at 60 minutes, adjusted for baseline. RESULTS: Baseline Ptco2 was 45 mmHg or lower for 16 participants with full data (73%). The mean difference in Ptco2 between high concentration and titrated oxygen therapy at 60 minutes was 3.2 mmHg (95% CI, 1.3-5.2 mmHg; P = 0.002). CONCLUSION: High concentration oxygen therapy increases Ptco2 in morbidly obese patients. Our findings support guidelines that advocate oxygen therapy, if required in patients with morbid obesity, be titrated to achieve a target Spo2 of 88-92%. CLINICAL TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry, ACTRN12610000522011.

Awake craniotomy for glioma resection: Technical aspects and initial results in a single institution.

INTRODUCTION: Although variations in the technique of awake craniotomy (AC) have been widely reported, a key member of this interdisciplinary procedure is the healthcare professional performing assessments of neurological function during resection. The expertise of the latter will depend on the neurological function to be tested and on available resources of the institution. This report details our initial experience of an AC service utilizing the expertise of a speech and language therapist (SLT) and an experienced neuro-physiotherapist (NP) to monitor patient function during glioma resection. METHODS: Forty-five patients underwent 50 AC procedures for eloquently located gliomas over a 3-year period. Patients with a glioma involving speech or sensorimotor areas were assessed preoperatively by the SLT/NP respectively. The same therapist monitored the patient's neurological function intraoperatively and executed a rehabilitation program tailored to the needs of the patient in the postoperative period. RESULTS: Three patients underwent biopsy only, due to intraoperative seizures precluding intraoperative mapping (2 cases) or speech arrest on stimulation of a small recurrent tumor. The remaining 47 cases were suitable for repetitive neurological assessment "awake" during tumor debulking. One patient with a large sensorimotor tumor developed intraoperative hemiparesis due to outward brain herniation (which recovered postoperatively). Ten patients developed a new or worsened neurological deficit in the initial postoperative period (6 were detected intraoperatively), of which 5 eventually had resolution and returned to baseline function within 2 weeks. CONCLUSIONS: In our initial experience based anecdotally on a previous similar "non-awake" caseload, we have found AC with the input of the SLT/NP to be a key component in ensuring optimal functional outcomes for patients with gliomas in eloquently located areas.

Bilateral plunging ranula: two case reports and a review of the literature.

AIM: Presentation of two bilateral plunging ranula cases and then review of the plunging ranula literature to understand current concepts on aetiology, imaging for diagnosis and management. METHOD: A literature review using PubMed (92 papers) and Google Scholar (18 papers) has revealed only 18 cases of bilateral plunging ranulas ever published and with the addition of the two cases presented this makes a total of 20. RESULTS: These cases are reviewed and information related to aetiology and management is presented. The cause appears to be a combination of mylohyoid dehiscence, racial predisposition and previous trauma to the mouth/face or previous oral surgery. CONCLUSION: Plunging ranula are a rare cause of bilateral and unilateral neck swellings but more common in Maori, Polynesian and Asian people. Their cause is multifactorial and ultrasound scan (USS) is the current investigation of choice. Management relies on excision of the sublingual gland with the cystic contents via a trans-oral approach.

Bilateral non-contiguous atypical papillary glioneuronal tumor: case report.

Papillary glioneuronal tumor (PGNT) was first described as a distinct clinic-pathological entity by Komori et al. in 1998. Since then it has been included as a mixed neuronal-glial tumor in the revised WHO (2007) classification of central nervous system tumors. On brain imaging, it appears as a demarcated, solid to cystic, contrast-enhancing mass usually located in the temporal lobe. Histologically, it is considered a biphasic tumor characterized by small cuboidal GFAP-positive astrocytes around hyalinised blood vessels and synaptophysin-positive interpapillary collections of neurocytes, large neurons and intermediate-sized "ganglioid cells". Although they are generally regarded as benign WHO Grade I tumors, recent reports have described more pathologically aggressive features. To date, these reports have all been single lesions.

Head injury from a bungee run.

An adaptation of bungee jumping, 'bungee running', involves participants attempting to run as far as they can whilst connected to an elastic rope which is anchored to a fixed point. Usually considered a safe recreational activity, we report a potentially life-threatening head injury following a bungee running accident.

What influences clinician's satisfaction with radiology services?

AIM: PACS and teleradiology systems have led to marked changes in the traditional relationship between referring clinicians and hospital radiology departments. The aim of this study was to assess which factors influence clinicians' satisfaction with modern radiology services. METHOD: An Internet-based survey questionnaire was sent to all referring clinicians within a large hospital network. RESULTS: Fifty-eight percent of 316 clinicians responded to the survey. Seventy percent felt PACS installation had improved reporting time, and 56% felt it had improved working patterns for medical staff. Approachability of radiologists was the only factor significantly associated with increased satisfaction (p = 8 × 10-8). A number of factors were found to be significantly associated with the perceived value of radiology reports, and these are discussed. An increase in clinicians' confidence in their own radiological skills was not associated with a decrease in the value they placed on radiology reports. CONCLUSION: The only factor significantly associated with improved clinician satisfaction was the availability of an approachable radiology service. Availability of PACS did not appear to undermine the value placed on radiology reports.

Spontaneous extrusion of guglielmi detachable coils from anterior communicating artery aneurysm.

Recurrence of coiled aneurysm usually due to coil compaction is a known phenomenon. Extent of recurrence and its relation to re-bleeding is not known. The authors report a case of spontaneous asymptomatic extrusion of guglielmi detachable coils from the dome of a previously ruptured anterior communicating artery aneurysm two years after the initial endovascular obliteration. The initial aneurysm had a suitable neck-aspect ratio for endovascular obliteration with uncomplicated coiling procedure. Extreme degree of coil compaction with subsequent expulsion of the coils from the dome due to water-hammer effect of blood flow is thought to be the main pathogenic mechanism of this rare but worrying complication. Surgical management includes clipping at the neck ensuring complete obliteration of the aneurysm. Postoperative angiogram to confirm its satisfactory obliteration is advised.